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Topical steroids awareness and abuse among medical students in
Jezan
Abstract:
Background
Topical steroids are considered to be one of the most
frequently abused drugs. Only a few studies tackled this
problem in the Gulf area.
Objectives
To investigate topical steroids awareness and abuse among
medical students in Jezan.
Subjects and methods
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Amani Ali Madkhali , AFAF NASSER HAKAMI, Meshari Abdullah Alwetaid, Hind Mag-bul Maghfuri, Deena Ahmed alghamdi, Yasmeen Rihan Albar, Nehad Khalaf Khawaji,Yazeed khalid alkhader, Hafsa Hafed Hassan, Abdullah Ahmad Alghamdy, Ebtesam
Eissa Ali Madkhali, Abdulrahman Hassan O Makin
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A cross-control study was conducted using an anonymous
web-based questionnaire. A total of 364 patients from Saudi
Arabia took part in this survey.
Participants were asked to fill an anonymous questionnaire
about their age, sex, their awareness about topical steroids
and reasons for using them. Data about the common adverse
events experienced were also collected.
Results
This survey included a total of 346 participants, of which 71%
were females. The mean age for the participants was 24.7
±4.2 years old. Less than half of the participants (n=152,
41.8%) used topical steroids mainly for pigment disorders
(n=52, 36.11%) and acne (n=48, 33.33%). The most
common adverse events reported by participants were
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acneiform, erythrma, hyperpigmentation and infection as
reported in 20 participants each, with a percentage of
13.16%.
Results also showed that 26.32% of patients who were taking
topical steroids were self-medicated.
Conclusion
In order to achieve the optimum treatment outcome, it is very
important to highlight the possible complications for topical
steroids abuse and misuse.
Additional studies should be conducted to investigate topical
steroids awareness and abuse.
Keywords
Steroids, Topical, Abuse, Awareness, Medical.
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Introduction
Topical steroids are considered to be one of the most widely
used medications for dermatologic therapy0F
1, 1F
2. At the same time,
abusing or misusing topical steroids is deemed to be a common
problem with them adding new complications as it was reported
in a number of studies2F
3, 3F
4.
Many studies have been conducted around the world to
investigate the different patterns of topical steroids prescribing
and usage4F
5, 5F
6. However, data on the Gulf region are still limited.
The most common side effects experienced by patients using
topical steroids are localized to sites of application6F
7.
Materials and Methods
Subjects:
A cross-control study was conducted using an anonymous
web-based questionnaire. A total of 364 patients from Saudi
Arabia took part in this survey.
Participants were asked to fill an anonymous questionnaire
about their age, sex, if they were using topical steroids, which
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preparations they were using and for how long they were
using them. Data about the common adverse events
experienced were also collected.
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Data collected:
The questionnaire consisted of 11 questions. The first two
questions were about age and gender. The third question was
"Did you use topical steroids before?", if the answer was
"yes", then the participant is required to answer the following
8 questions;
1. Which type of preparation in topical steroids you usually
use?
2. What is the type of Topical Corticosteroids you used to
use?
3. How long do you use steroids?
4. What is the frequency of Topical Corticosteroids
application?
5. What is your source of information about topical
steroids?
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6. What is your chief complain of topical corticosteroids?
7. Why do you use corticosteroids?
8. What is the common adverse effects of Topical
Corticosteroids?
Statistical analysis:
Data were statistically described in terms of frequencies
(number of cases) and valid percentages for categorical
variables. Mean, standard deviations, minimum and maximum
were used to describe numerical variable. All statistical
calculations were done using computer program IBM SPSS
(Statistical Package for the Social Science; IBM Corp,
Armonk, NY, USA) release 21 for Microsoft Windows.
Results
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Data collected showed that the mean age for the participants
was 24.7 ±4.2 years old. With a maximum age of 52 years
and minimum age of 19 years old.
Statistic Std. Error
Age
Mean 24.706 .2293
95% Confidence Interval
for Mean
Lower Bound 24.255
Upper Bound 25.157
5% Trimmed Mean 24.225
Median 24.000
Variance 17.884
Std. Deviation 4.2289
Minimum 19.0
Maximum 52.0
Range 33.0
Interquartile Range 2.0
Skewness 4.000 .132
Kurtosis 21.474 .264
It was found that the majority of participants were females
(256, 71%) while 104 were males (28.8%).
Sex
Frequency Percent Valid Percent
Valid
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Female 256 70.3 71
Male 104 28.6 28.8
Total* 360 100.0 100.0
* 4 missing values.
Participants were asked about their previous usage of topical
steroids. 152 (41.8%) answered yes while 212 (58.2%)
answered no.
Did you use topical steroids before
Frequency Percent Valid Percent
Valid
No 212 58.2 58.2
Yes 152 41.8 41.8
Total 364 100.0 100.0
Participants were also asked types of topical steroids
preparation they usually use. The most frequent type used
was mild steroids as reported in 96 patients (63.16%). Triple
combination and potent steroids were used by 32 (21.05%)
and 24 (15.79%) participants respectively.
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Which type of preparation in topical steroids you usually use
Frequency Percent Valid Percent
Valid
Mild steroids 96 63.16 63.16
Potent steroids 24 15.79 15.79
Triple combination 32 21.05 21.05
Total 152 100.0 100.0
Data collected showed that Betamethasone was the most
frequent type used as reported in 48 (36.36%) participants,
followed by Clobetasol (30.30%), Mometasone and Panderm
in 20 (15.15%) participants each. Lastly, Dermovate in 4
(3.03%) participants.
What is the type of Topical Corticosteroids you used to use
Frequency Percent Valid Percent
Valid
Betamethasone 48 31.58 36.36
Clobetasol 40 26.32 30.30
Dermovate 4 2.63 3.03
Mometasone 20 13.16 15.15
Panderm 20 13.16 15.15
Total* 132 100.0 100.0
* 20 missing values.
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Regarding duration of topical steroids usage, it was found that
the majority of the participants (108, 71.05%) used steroids
for 6 months or less. 28 (18.42%) used steroids from 6 to 12
months, 12 (7.89%) continued to use steroids for more than
2 years and only 4 (2.63%) participants used steroids from
one to two years.
How long do you use steroids
Frequency Percent Valid Percent
Valid
>2 Years 12 7.89 7.89
0-6 months 108 71.05 71.05
1-2 years 4 2.63 2.63
6 to 12 months 28 18.42 18.42
Total 152 100.0 100.0
As for frequency of topical steroids application, 80 (52.63%)
participants were found to be using topical steroids once daily
and 32 (21.05%) used steroids twice daily. Twenty four
(15.79%), 8 (5.26%) and 8 (5.26%) participants were found
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to be using steroids intermittently, once weekly and on
alternate days respectively.
What is the frequency of Topical Corticosteroids application
Frequency Percent Valid Percent
Valid
Alternate days 8 5.26 5.26
Daily once 80 52.63 52.63
Daily twice 32 21.05 21.05
Intermittently 24 15.79 15.79
Weekly once 8 5.26 5.26
Total 152 100.0 100.0
Pharmacies were found to be the main source of information
about topical steroids as reported in 44 (28.95%)
participants, closely followed by self-medication as reported in
40 (26.32%) participants. Thirty two (21.05%) reported that
beauticians were their source of information about topical
steroids, 20 (13.16%) and 16 (10.53%) referred to
advertisement and relatives/friends respectively to be their
source about topical steroids.
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What is your source of information about topical steroids
Frequency Percent Valid Percent
Valid
Advertisement 20 13.16 13.16
Beautician 32 21.05 21.05
Pharmacy 44 28.95 28.95
Relatives/friends 16 10.53 10.53
Self 40 26.32 26.32
Total 152 100.0 100.0
Participants were asked about their chief complain for that
they used topical steroids, and the following was revealed;
Dry facial skin and diffuse facial redness with hotness were
the most frequent chief complains reported as found in 32
(21.05%) participants each. Burning /itching, Papular rash
without pustules and Papulopustular lesions were reported in
16 (10.53%) participants each. Twelve (7.89%) participants
reported using topical steroids for rebound phenomenon and
28 (18.42%) participants used topical steroids for no clear
reason.
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What is your chief complain of topical corticosteroids
Frequency Percent Valid Percent
Valid
Burning /itching 16 10.53 10.53
Diffuse facial redness with
hotness
32
21.05 21.05
Dry facial skin 32 21.05 21.05
Nothing 28 18.42 18.42
Papular rash without
pustules
16
10.53 10.53
Papulopustular lesions 16 10.53 10.53
Rebound phenomenon 12 7.89 7.89
Total 152 100.0 100.0
Fifty two (36.11%) participants used topical steroids for
pigment disorders, 48 (33.33%) used them for acne, 24
(16.67%) for their whiteness effect and 20 (13.89%)
participants used steroids as fairness cream.
Why do you use corticosteroids
Frequency Percent Valid Percent
Valid
Whiteness effect 24 15.79 16.67
Acne 48 31.58 33.33
Fairness cream 20 13.16 13.89
Pigment disorder 52 34.21 36.11
Total* 144 100.0 100.0
* 8 missing values.
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Participants were also asked if they experienced adverse
events during or after using topical steroids and the following
was revealed;
Acneiform, erythrma, hyperpigmentation and infection were
reported in 20 participants each, with a percentage of
13.16%. Atrophy and telangiectasia were reported in 16
participants each, with a percentage of 10.53%.
Hypertrichosis was reported in 8 (5.26%) participants and
lastly hypopigmentation was reported in 4 (2.63%)
participants. Twenty eight (18.42%) participants stated that
they do not know whether they had adverse events or not.
What is the common adverse effects of Topical Corticosteroid
Frequency Percent Valid Percent
Valid
Acneiform 20 13.16 13.16
Atrophy 16 10.53 10.53
Erythrma 20 13.16 13.16
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Hyperpigmentation 20 13.16 13.16
Hypertrichosis 8 5.26 5.26
Hypopigmentation 4 2.63 2.63
I don't know 28 18.42 18.42
Infection 20 13.16 13.16
Telangiectasia 16 10.53 10.53
Total 152 100.0 100.0
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Discussion
The aim of this survey was to investigate topical steroids
awareness and abuse among medical students in Jezan.
A total of 364 patients from Saudi Arabia took part in this
survey.
The significant relief of symptoms from using topical steroids
preparations led to types of abuse by both non specialists and
patients8, that is why it was important to investigate the different
patterns of topical steroids prescribing and usage.
Our results showed that Betamethasone and Clobetasol were the
most frequent types used as reported in 36.36% and respectively
30.30% of the participants. Numerous studies reported similar
results regarding Betamethasone9, 10, 11, 12, however, regarding
Clobetasol, different percentages were reported in the same
studies12.
Around three quarters (71.05%) of the steroids users used
steroids for 6 months or less. Around half of the steroids users
(52.63%) were found to be using topical steroids once daily.
Both findings were similar to a study conducted in India by
Inakanti et al., as it showed that 77.7% used topical steroids for
3-6 months and the majority of cases applied daily once (37%)
Numerous studies named the main source of recommendation or
prescription9-12, but in our study, pharmacies were found to be
the main source of information about topical steroids as reported
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in 44 (28.95%) participants, closely followed by self-medication
as reported in 40 (26.32%) participants. Thirty two (21.05%)
participants reported that beauticians were their source of
information about topical steroids.
Our results showed that dry facial skin and diffuse facial redness
with hotness were the most frequent chief complains reported as
found in 32 (21.05%) participants each. However, many studies
stated that acne was the most chief complain reported9-12.
Fifty two (36.11%) participants used topical steroids for
pigment disorders, 48 (33.33%) used them for acne, 24
(16.67%) for their whiteness effect and 20 (13.89%) participants
used steroids as fairness cream.
Acneiform, erythrma, hyperpigmentation and infection were
reported in 20 participants each, with a percentage of 13.16%,
followed by atrophy and telangiectasia as they were reported in
16 (10.53%) participants.
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Conclusion
In order to achieve the optimum treatment outcome, it is very
important to highlight the possible complications for topical
steroids abuse and misuse.
Additional studies should be conducted to investigate topical
steroids awareness and abuse.
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References
1 Deshmukh, V., Bhamare, C., Rathod, S., Motghare, V., Deshpande, R. and Patil, J. (2013). Prescribing practices of topical corticosteroids in the outpatient dermatology department of a rural tertiary care teaching hospital. Indian Journal of Dermatology, 58(5), p.342. 2 Rathi, S. and D′Souza, P. (2012). Rational and ethical use of topical corticosteroids based on safety and efficacy. Indian Journal of Dermatology, 57(4), p.251. 3 Gupta, Y., Kumar, S. and Goyal, A. (2016). Abuse of topical corticosteroids in India: Concerns and the way forward. Journal of Pharmacology and Pharmacotherapeutics, 7(1), p.1. 4 Coondoo, A., Phiske, M., Verma, S. and Lahiri, K. (2014). Side-effects of topical steroids: A long overdue revisit. Indian Dermatology Online Journal, 5(4), p.416. 5 Nerurkar, R., Kokane, M. and Mehta, M. (2016). Study of prescribing pattern of topical corticosteroids in dermatology out patients department in a tertiary care hospital in India. [online] Available at: http://www.ijbcp.com/index.php/ijbcp/article/view/662 [Accessed 8 Jan. 2018]. 6 KB, B., Patil, R. and Pillai, R. (2015). Drug prescribing pattern of topical corticosteroids in dermatology unit of a tertiary-care hospital. International Journal of Medical Science and Public Health, 4(12), p.1702. 7 Berth-Jones J. Topical therapy. In: Burns T, Breathnach S, Cox N, Griffiths C, editors. Rooks Textbook of Dermatology. 8th ed. 73. Vol. 1. UK: Blackwell Science Ltd; 2010. pp. 1–73. 8 Nagesh, T. and Akhilesh, A. (2016). Topical steroids awareness and abuse: A prospective study among dermatology outpatients. Indian Journal of Dermatology, 61(6), p.618.
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9 Saraswat, A., Lahiri, K., Chatterjee, M., Barua, S., Coondoo, A., Mittal, A., Panda, S., Rajagopalan, M., Sharma, R., Abraham, A., Verma, S. and Srinivas, C. (2011). Topical corticosteroid abuse on the face: A prospective, multicenter study of dermatology outpatients. Indian Journal of Dermatology, Venereology, and Leprology, 77(2), p.160. 10 Bhat, Y., Manzoor, S. and Qayoom, S. (2011). Steroid - induced rosacea: A clinical study of 200 patients. Indian Journal of Dermatology, 56(1), p.30. 11 Rathi, S. and Kumrah, L. (2011). Topical corticosteroid-induced rosacea-like dermatitis: A clinical study of 110 cases. Indian Journal of Dermatology, Venereology, and Leprology, 77(1), p.42. 12 Inakanti, Y., Rao Thimmasarthi, V., Anupama, Kumar, S., Nagaraj, A., Peddireddy, S. and Rayapati, A. (2015). Topical corticosteroids: Abuse and Misuse. Our Dermatology Online, 6(2), pp.130-134.
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